Name of Provision:
		
Designation:	e.g. Foundation Special School / Local Authority Service / Academy

County & Area:
		
Address:

		
Staff:
	FTE teachers:		Support Staff: 		Admin Staff:		
Name of Hospital(s) you provide
education for:
		
Key Contact Name:
		
Job Title:
		
Email Address:
		
Website:
		
Governance:
	e.g. Governing Body / Management Committee / Trust board / LA
	
Age range taught:

Settings within your provision:

Please tick all which apply
	
Hospital inpatient	
□	
CAMHS inpatient unit	
□	
Other	
□	
	Home Tuition/
Outreach Service	
□	
Day School	
□		
 Out of school hours offer, e.g. 
Holiday provision:	

Suggested areas of specialism you could 
Contribute to the NAHE:
		
Declarations:
1.	I understand that the NAHE is a company limited by guarantee and that, in the case of it folding, we would be liable to pay £1 towards the wind-up costs as described in the articles of association.
2.	My governing body / management committee / Trust board / Local Authority (whichever is relevant) is aware of this application.	
Please tick to indicate that you understand the declarations as set out above	□	
PLEASE SELECT ANNUAL MEMBERSHIP LEVEL	
A	Individual	£60	□	
B	Organisation (fewer than 10 staff)	£80	□	
C	Organisation (between 10 – 30 staff)	£160	□	
D	Organisation (more than 30 staff)	£240	□